2:00

Doctors who treat obesity are excited

2:02

about this new medicine because in

2:04

trials, people on the zip bound lost

2:06

more than 20% of their body

2:08

weight over about a year and a half. The

2:11

manufacturer, Eli Lilly, cautions that

2:13

the drug works best in

2:15

conjunction with a reduced calorie

2:17

diet and extra exercise.

2:20

Novo Nordisk, the maker of a

2:22

competing weight loss drug called Wegovi,

2:25

has been spending a lot of

2:27

money on physicians who are opinion

2:29

leaders in the field of obesity

2:31

treatment. A Reuters special

2:33

report reveals that the Danish drug company

2:36

spent over $25 million during

2:39

the past decade on travel

2:41

and consulting fees for influential

2:43

physicians. This covers promotion

2:45

of both Wegovi and an earlier

2:47

anti-obesity drug called Saxenda.

2:50

According to the report, at least 57 doctors

2:53

in the US have accepted $100,000 or more from Novo

2:57

Nordisk. Many are members

2:59

of the Obesity Society. Some leading experts

3:01

have received more than a million dollars

3:03

in consulting fees and promotional talks. These

3:07

drugs do have some potentially serious

3:09

side effects, including nausea, vomiting, diarrhea,

3:12

and muscle loss. When people stop these

3:14

medications, they often regain the weight they

3:16

lost. Many years ago,

3:18

scientists conducted a head-to-head trial of

3:21

blood pressure medications. They

3:23

wanted to know which antihypertensive worked

3:25

better. A thiazide-type diuretic,

3:27

a calcium channel blocker, or

3:29

an ACE inhibitor. The

3:31

All Hat trial has now gathered data for up

3:33

to 23 years. Researchers

3:36

analyzed the follow-up data to detect

3:38

any differences in mortality among

3:40

the three different types of treatment. There

3:43

were 32,800 volunteers who started the trial. Cardiovascular

3:49

mortality and most other outcomes were

3:51

quite similar among the three groups.

3:53

An earlier analysis had shown a

3:56

higher rate of heart failure among

3:58

participants taking the calcium channel

4:00

blocker and lotopine compared

4:02

to the diuretic chlorothalidone.

4:05

In this analysis, people taking the

4:07

ACE inhibitor lisinopril were 11% more

4:10

likely to have a stroke than

4:12

those on the diuretic. The

4:14

risk of dying from a stroke was 19% higher

4:18

than if they had been taking

4:20

chlorothalidone. These risks were

4:22

apparent long after the trial period

4:24

ended. According to

4:27

our calculations, over 40 million

4:29

Americans take one of the

4:31

three most popular cholesterol-lowering statin-type

4:34

medications, atorvastatin, simvastatin, and rosubastatin,

4:36

that represents over 5 billion

4:39

pills annually and makes statins among

4:41

the most prescribed drugs in America.

4:44

But a research report in the Annals of

4:46

Internal Medicine concludes only about a

4:48

third of eligible people are taking

4:50

statins. The authors suggest that

4:53

many more people should be taking

4:55

statins to comply with guidelines. If

4:58

you've ever enjoyed sushi at a Japanese

5:00

restaurant, you might be familiar with wasabi.

5:03

It's an innocuous-looking pale green

5:05

condiment that packs a powerful

5:08

wallop. Now researchers have

5:10

determined that the ingredient primarily

5:12

responsible for the flavor can

5:14

actually boost brain power. The

5:16

Japanese scientists recruited 72 individuals

5:19

at least 60 years old. After

5:22

initial cognitive testing, these

5:24

people started consuming 6-methyl

5:27

sulfonylhexyl isothiocyanate,

5:29

or placebo. They took capsules so

5:32

the taste wouldn't give it away. After

5:34

three months of supplementation, the

5:36

volunteers took another battery of

5:38

tests. They had significant improvements

5:41

in their episodic and working memories,

5:43

though none in other cognitive domains.

5:46

They suspect that the

5:49

anti-inflammatory and antioxidant activity

5:51

of 6-MS ITC may

5:54

be responsible. And

5:56

that's the health news from the People's Pharmacy

5:58

this week. Welcome

6:15

to the People's Pharmacy. I'm Joe Graden.

6:17

And I'm Terry Graden. Americans

6:20

take a lot of medicines. The

6:22

latest data suggests that pharmacists dispensed

6:24

nearly 7 billion prescriptions

6:27

last year. At least

6:29

a fifth of adults take five or

6:31

more medicines. That doesn't include

6:33

over-the-counter drugs, which means a

6:35

lot of people are taking

6:37

multiple medications. This is especially

6:39

true for older Americans. It's

6:42

not unusual for someone to have an

6:44

array of prescription bottles on their kitchen

6:46

counter or nightstand. Sometimes

6:48

all those pills can cause

6:51

unexpected problems. To find out more

6:53

about the hazards of too much medicine

6:55

and what can be done about it,

6:58

we are talking with Dr. Delon Canterbury.

7:00

He's the founder of

7:03

Geriatrics and Deprescribing Accelerator.

7:05

Dr. Canterbury is a board-certified

7:08

geriatric pharmacist with a passion

7:10

for reducing harmful medication use

7:12

in older adults across the

7:14

country. We

7:17

are so excited to have

7:19

in our studio today Dr.

7:21

Delon Canterbury. He is a

7:24

board-certified geriatric pharmacist and

7:27

the founder of Geriatrics

7:30

and the Deprescribing Accelerator. We think

7:33

all of these things are incredibly

7:35

important. Welcome to the

7:37

People's Pharmacy, Dr. Delon Canterbury. Yes. Thank

7:39

you so much for having me, Joe

7:41

and Terry. Appreciate you guys having me

7:43

on today. Pleasure to be here. So,

7:46

Dr. Canterbury, what

7:48

is a board-certified

7:50

geriatric pharmacist? You're

7:52

not very old. I

7:54

love it. I get

7:56

that joke a good bit actually. Just

8:00

like how we have different types of

8:02

medical doctors, right, we may have different

8:04

pharmacists that can specialize. So there are

8:07

pharmacists that specialize in cardiology, you know,

8:09

ambulatory care, or even nephrology

8:11

for the kidneys. I had to focus

8:14

more on the older population. So yeah, I am a little

8:16

bit younger if you can tell, but I

8:18

got my board certification in 2017. And

8:21

so this is something a pharmacist

8:23

can test and train for outside of

8:25

pharmacy school. Why is it

8:28

so important? Well, for

8:30

me, we honestly don't

8:32

have enough pharmacists in this space.

8:35

You know, about 1% of

8:37

all pharmacists are trained in geriatrics.

8:40

And the truth is, as you guys know,

8:42

we have an aging population that's growing and

8:45

growing, and caregivers that aren't getting the support

8:47

they need in managing those meds. So I

8:49

decided to focus more on this space after

8:52

seeing how many of my older patients, honestly,

8:54

I didn't know how to treat or manage

8:56

in the retail setting. And

8:58

that inspired me to get into the

9:00

aging population, use this voice to advocate,

9:03

and highlight some of the issues that I saw in

9:06

the community setting. When

9:08

we spell geriatrics, and

9:10

Terri, you could help me

9:12

here, G-E-R-I-A-T-R-I-C-S. Correct.

9:17

But you spell geriatrics

9:20

a little differently. You're

9:22

the founder of geriatrics.

9:25

Spell it, please. Yeah,

9:27

geriatrics, G-E-R-I-A-T-R-X as an

9:30

x-ray. Now,

9:32

of course, older people do take

9:35

a lot of medications. They

9:37

take more medicines than younger people because

9:39

they've got more stuff wrong with them.

9:42

But one of the things we've noticed

9:44

over the years is that sometimes

9:46

a doctor will prescribe a medication

9:49

for a person who has a problem,

9:52

and then that

9:54

medicine may cause side effects. And

9:57

that doctor, or sometimes a different doctor,

10:00

prescribe a medicine to address the

10:02

side effects from the first medicine

10:04

and you get into a whole

10:06

cascade of problems, if

10:08

I may say so. How do

10:11

you address that? We find that

10:13

doctors are sometimes a little reluctant

10:15

to take people off medicines. No,

10:18

it's an excellent question and an

10:20

amazing choice of word with cascade.

10:22

So you're definitely referring

10:25

to the prescribing cascade, right, where

10:27

one medication is being used to

10:29

treat another side effect of another

10:31

medication instead of it being seen

10:33

or mistaken as a new health

10:35

condition. And this happens a lot

10:37

in our older generation, right? When I average,

10:39

they're taking way more than five medications, in

10:41

fact, usually more than 10. There

10:44

may be some hesitancy, but

10:46

what I have found in this space, truthfully,

10:49

is that our prescribers aren't

10:51

exactly the ones the most trained in

10:53

pharmacology and medicine and understanding some of

10:56

those side effects, some of those patterns

10:58

we see in those med lists. And

11:00

that's where our pharmacists on that care

11:02

team can educate and use that as

11:04

an opportunity to show, hey, did you

11:06

realize that this certain blood pressure med

11:08

is actually causing a foot swelling? So

11:11

you don't necessarily need another diuretic. We

11:13

can just remove or change that drug

11:15

to another. And an example like that

11:17

can happen 10 times over,

11:19

right? It can happen with people on

11:21

long-term omaprazole or

11:24

heartburn medicines, and there's an

11:26

association of having pneumonia with

11:28

chronic use of that and even falls and

11:30

fractures. So kind of just tying the pieces

11:32

to the puzzle and working backwards instead of

11:34

just seeing it as, oh, you have this,

11:37

therefore you need this. We got to get

11:39

out of this pill for every ill mentality.

11:42

And it sounds as though you're really

11:44

actually trying to look at the whole

11:46

picture, the big picture of the patient

11:48

as an entire person rather than just

11:50

one little

11:52

data point for perhaps their blood pressure.

11:55

Correct. It has to be holistic

11:57

based. It has to be lifestyle

11:59

medicine I can't just look at it

12:01

and say, hey, this is what we got

12:03

to do. We have to look at what the patient wants.

12:05

Do they want to be on the meds? Do they want

12:07

to get off the meds? Do they know they can get

12:10

off the meds? What do they want out of life? And

12:12

so when I have these deprescribing conversations, it's around how

12:15

do we maintain that quality of life

12:17

in that person-centered care. Now,

12:19

Dr. Canterbury, there are

12:21

a lot of health professionals out there, and

12:24

even some patients for that matter, who

12:27

adopt a mantra

12:29

called don't mess

12:31

with success. In

12:34

other words, well, it's working. Let's

12:36

not rock the boat. You

12:39

mentioned the blood pressure medicine

12:41

that might cause swelling

12:43

of the ankles. Give us

12:46

an example of a blood pressure pill

12:48

that might do that, for example. Yeah, yeah, sure.

12:51

Also commonly seen one is

12:53

amylodipine, pretty much

12:55

the first line blood pressure medicine. And

12:58

amylodipine is prescribed in huge quantities. It's

13:00

one of the top blood pressure medications.

13:02

So somebody ends up having to maybe

13:05

change their shoe size. I used to

13:07

be a size 10. Now

13:09

I'm a size 11 because my foot doesn't fit

13:11

anymore. And so what

13:14

would often happen would be, oh,

13:16

well, we'll prescribe hydrochlorothiazide, a

13:19

diuretic, get rid of that

13:21

excess fluid. But

13:23

then hydrochlorothiazide depletes the body

13:25

of potassium. So now

13:27

we have to add potassium. And potassium

13:29

may cause some abdominal

13:32

complaints. So now we're

13:35

back to the omeprazole that you just

13:37

mentioned, the PPI, Prilosec. And

13:40

so this cascade, as Terry described

13:42

it, is not uncommon. Doctors

13:46

are very comfortable

13:48

with, you know, it works.

13:52

Why should we change anything?

13:55

And doctors are often in silos. So

13:57

the doctor who prescribed the blood pressure

13:59

pill... is not the same doctor

14:01

who's dealing with the digestive upset caused

14:04

by the potassium. Love

14:06

it. Yeah, and it's spot on that you

14:08

say that. I mean, I don't love it.

14:11

It's terrible, but it happens all the time,

14:13

right? This prescribing cascade can be quite insidious.

14:16

And so for me, I have to frame

14:18

the convo around when it comes to the

14:20

clinicians is, you know, when things start, you

14:22

know, we have to treat it like a

14:24

puzzle. Like when we added this, what

14:27

change in the person's care? What was the

14:29

difference? What was a new condition, quote unquote,

14:31

that came about? And we were able to

14:33

work backwards and show that kind of trajectory,

14:35

which you aptly delineated it.

14:38

You can use that as your argument to show,

14:41

hey, we can do this better. Let's just work

14:43

backwards and taper them off. One

14:45

of the things that occurs to me is that

14:47

Joe mentioned that doctors often are practicing

14:49

in silos. And I'm thinking, and

14:52

they only have a few minutes per patient.

14:54

Yeah. How do

14:56

you get involved with this? Yeah,

14:58

excellent point. Yeah, you're

15:00

right. On average, I can say 15 minutes,

15:02

12 minutes average per visit. And

15:05

honestly, there are structural barriers around

15:08

this medication deprescribing approach. One, let's

15:10

talk about the root issue. They're

15:13

not educated on this prescribers

15:15

simply are not taught about the concepts

15:17

of deprescribing. It's more so we're trained

15:19

to treat and manage care.

15:21

Right. And so there has to

15:23

be a shift in our general medication education.

15:26

And it shouldn't just be all a doctor

15:28

because they have tons of other competing priorities,

15:30

prior authorizations, long waits, you know it. But

15:33

when it comes to these silos,

15:36

right, I think we also need

15:38

to incentivize having more of this

15:40

conversation by leveraging your pharmacist. And

15:42

I don't think, you know, necessarily

15:44

every community pharmacist wants to do

15:46

that. But this is where medicine

15:48

is going. And so to take

15:50

off the burden of prescriber, have

15:53

a, like, for instance, we use a concierge

15:55

approach in our company, we do this for

15:57

patients. So we give our patients a an

16:00

hour and a half, whatever time they need

16:02

to understand every medication as much as possible.

16:05

And then we communicate those concerns with the

16:07

doctor. So it's not necessarily being done in

16:09

clinic. It's being done in the patient's home,

16:11

whether it be virtual or through a phone

16:13

call or through the caregiver. So

16:15

one, we got to start using pharmacists. Two, we

16:18

have to give them at least

16:20

more structural incentive because the industry just incentivized

16:22

people to be on more and more pills.

16:25

So we got to get out of the

16:27

sick care method and get back into the

16:29

more proactive approach. One

16:31

of the things that I think that is a

16:33

challenge for both prescribers

16:35

and dispensers these days are

16:38

the direct-to-consumer ads. Oh, yeah. They're

16:41

everywhere. They're all the time.

16:44

They're very appealing. Take this and you'll be

16:46

happy. Take this and you'll be well. So

16:49

how do we get out of this mentality

16:52

of a pill for every ill because that's

16:54

what television is telling us. Man.

16:58

It's a loaded question, my man.

17:00

But it can be done. We

17:02

can reframe this narrative we've been

17:04

force-fed for so long, but it

17:06

starts with the patient being empowered.

17:09

So education is the first step

17:11

in having a trusted messenger shuttered

17:13

other ways outside of medicine using

17:15

non-pharmacological approaches, stress management, sleep hygiene.

17:17

We talked about those first before

17:20

getting to those band-aids that

17:22

we call medicines. You

17:25

are listening to Dr.

17:27

Delon Canterbury, founder of

17:29

Geriatrics and the De-Prescribing

17:32

Accelerator. Dr. Canterbury

17:34

is a board-certified geriatric

17:36

pharmacist with a passion

17:38

for reducing harmful medication

17:41

use in older adults across the

17:43

country. Terry, there was an article

17:45

in JAMA two weeks ago and

17:48

it pointed out that it's much

17:50

easier for health professionals to prescribe

17:52

medicines than to de-prescribe. It's

17:55

so good that this is finally getting

17:57

some public attention. After the break, we'll...

17:59

You'll find out more

18:01

about Dr. Canterbury's deprescribing

18:04

accelerator. Why is

18:06

deprescribing so important for older

18:08

patients? You'll also hear about the

18:11

beers list. It has nothing to

18:13

do with beverages. One

18:15

tricky part of deprescribing could

18:17

be a discontinuation syndrome, symptoms

18:20

from stopping a drug. Sometimes pharmacists

18:22

face significant challenges if they want

18:24

to question a drug or combination

18:27

of medications. You're

18:39

listening to The People's Pharmacy with Joe

18:41

and Terry Graydon. This

18:44

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19:51

Welcome back to The People's Pharmacy.

19:53

I'm Joe Graydon. And I'm Terry

19:55

Graydon. The People's Pharmacy is made

19:57

possible in part by Cocovia

19:59

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20:16

Do you know someone who's taking a

20:18

handful of pills? You might

20:21

know several such people. It's not uncommon

20:23

for a person to take two or

20:25

three different blood pressure medications, a

20:28

statin-type cholesterol-lowering drug, something to

20:30

control pain, such as a

20:33

non-steroidal anti-inflammatory drug like ibuprofen

20:35

or naproxen, and possibly

20:37

even a medicine to control blood sugar

20:40

like metformin. A recent article

20:42

in JAMA was titled, Deciding

20:44

When It's Better to Deprescribe

20:47

Medicines Than to Continue Them.

20:50

The author mentions prescribing

20:52

inertia, the tendency to keep

20:54

prescribing a drug even if it's no longer

20:56

needed. Pharmacists can play

20:58

a critical role in evaluating the

21:01

need for each medicine. They also

21:03

serve as a safety net to

21:05

catch dangerous drug interactions. But

21:08

pharmacists are under increasing time

21:10

pressure. As a result of

21:12

the hectic pace in most

21:14

pharmacies these days, pharmacists have

21:16

no time to take breaks

21:18

or even go to the

21:20

bathroom. It's little wonder that

21:22

patients may be reluctant to

21:24

bother the busy pharmacist for

21:26

information about deprescribing. To learn

21:28

why deprescribing is important and

21:31

how it can be done safely,

21:33

we're talking with Dr. Delon

21:35

Canterbury. He's the

21:37

founder of Geriatrics and

21:39

the Deprescribing Accelerator. Dr.

21:41

Canterbury is a board-certified

21:44

geriatric pharmacist with a

21:46

passion for reducing harmful

21:48

medication use in older adults.

21:52

Dr. Canterbury, you

21:54

have created

21:56

the Deprescribing Accelerator. What

22:02

is it and why

22:04

is it so very

22:06

important? Yeah, so I

22:08

started my company Geriatrics

22:10

in 2020 focusing on

22:12

providing those one-on-one concierge services

22:15

to families and caregivers and

22:17

older adults. And

22:19

in doing that for a couple of years,

22:21

figuring out the game, knowing what tools to

22:23

use, what tests

22:25

we can provide, what other kind of

22:29

really relevant clinical pearls, I decided

22:32

to package that into a

22:34

course for clinicians. So

22:37

my reason behind this

22:39

was because my grandmother suffered

22:41

from an inappropriate medication side

22:44

effect. She was in a nursing

22:46

home, she had mild dementia, they gave

22:48

her an antipsychotic inappropriately with an

22:50

FDA black box warning saying, don't

22:52

use in dementia. They did it

22:55

and her symptoms declined. And

22:58

so my parents had to deal with everything

23:00

as a caregiver, moving her, managing

23:02

her care, child proofing the home, her mild

23:06

dementia turned to severe. And so that

23:08

got me into this space and seeing

23:10

that why are we paying for

23:12

people to die slowly in these

23:15

facilities? Why are we paying

23:17

hard-earned money that we've worked as citizens to

23:20

not have optimum quality care for

23:22

a medication error? So

23:24

I created this course specifically to

23:26

teach other clinicians to keep that

23:28

from happening, whether you be a

23:30

pharmacist, a nurse, a social worker,

23:33

or even a prescriber or PA.

23:35

All of them, I believe, need to

23:38

be educated on deprescribing. And so my

23:40

mission in vision with deprescribing is

23:42

to change the narrative of medicine

23:44

and have us get to these

23:46

more lifestyle approaches, these more root

23:49

cause issues, and use as much

23:51

non-pharmacological interventions as possible. And

23:53

deprescribing, especially in our older adults

23:55

who suffered the most from polypharmacy

23:57

and medication harm, is my

24:00

goal. focus. Now I

24:02

would like to ask about something that's going

24:04

to start out sending kind

24:06

of technical and we

24:09

need to de-technicalize it so

24:11

that all of our listeners can get on

24:13

board with us. I'd

24:16

like to ask you about something called

24:18

the beers list. This is a list

24:20

that was put together many years ago

24:22

by a gentleman

24:24

named beers who said

24:27

a lot of these drugs these are

24:29

the drugs we should be especially paying

24:31

attention to and especially not prescribing to

24:33

older people. Tell us more about it please.

24:36

Yeah the beers list is my best friend

24:38

and I do like beer either way but

24:41

seriously Mark beers was a renowned geriatrician

24:43

in the 90s who developed this essentially

24:45

this 200 to 300 drug list

24:49

detailing to other clinicians which

24:51

medications may be potentially inappropriate

24:53

in people over 65 not

24:57

in a hospice setting but more in

24:59

community dwelling adults and

25:02

this list is so vital

25:04

when it comes to me

25:06

building these cases for deprescribing

25:08

because it really highlights

25:11

the types of classes of medications it

25:13

highlights whether you may have poor kidney

25:15

function or great kidney function or poor

25:17

liver function it goes into detail and

25:20

even characterizes that by the health condition

25:22

so if you have say dementia which

25:25

medications do you avoid with dementia if

25:27

you have heart failure which medications do

25:30

you avoid with heart failure so it

25:32

was the first of its kind in

25:34

our country to essentially help other fellow

25:36

geriatricians managing these older adults kind

25:39

of have a hit list of

25:41

what meds may be problematic it

25:43

doesn't mean they're all big no-nos

25:45

or harmful but it does delineate

25:47

really clearly and anyone can use

25:49

it as a freely available resource

25:52

to check out which meds you should watch out

25:54

for and why it gives you a rationale and

25:57

clinical evidence to why and it gets

25:59

updated every so often Yeah, update it

26:01

every about three years. We just had

26:03

a recent update launched this past May

26:07

2023. So check that out. It's freely

26:09

available. They also have an app as well.

26:11

So now it's taken

26:13

over by the American Geriatric Society,

26:16

which is who sponsors and helped

26:18

to fund that. So yeah, it's

26:20

now considered the American Geriatric Society

26:23

BEERS criteria. I

26:25

wish every pharmacist, every nurse

26:28

practitioner, every PA, and every

26:30

physician would check the

26:32

BEERS list every time they write a

26:35

prescription for somebody over the age of

26:37

maybe even 60. Because

26:41

some of these drugs should not be prescribed

26:45

end of point.

26:47

That's it. Full stop. Well,

26:50

and of course, you don't know. Aging

26:52

is so different. Some people are really

26:55

pretty aged by the time they get to 60. And

26:58

others are really doing okay

27:00

until they're almost 80. Oh,

27:03

yeah. Oh, yeah. People are living longer.

27:05

We have the evidence that supports it. And

27:07

again, I'm not against medicines keeping us living

27:09

longer and healthier, but I'm with you. We

27:11

don't do that enough. And there's always this,

27:14

we don't have the time, there's alert

27:16

fatigue, whatever excuse you want to make it.

27:18

If you're treating the patient like it's your

27:20

actual loved one, you're going to do all

27:23

you can. We're going to come back to

27:25

that alert fatigue issue in a minute, because

27:27

that is so very important in our day

27:29

of computerized everything.

27:32

But first, Dr. Canterbury, I've

27:36

got a problem with discontinuing

27:39

medications. Okay. I mean,

27:42

you're talking about deprescribing, and we are totally

27:44

on board with deprescribing. And we're going to

27:46

tell you a little story about

27:50

a patient who had

27:52

a really great outcome after she

27:55

had been deprescribed, so to speak.

27:57

But first, it's

27:59

hard. It's hard to stop many

28:01

medications because when

28:04

you stop them, there's something

28:06

called withdrawal. Now,

28:09

the FDA, in

28:12

its infinite wisdom, in

28:14

its official prescribing information, has

28:16

come up with a, I'll

28:18

call it a sanitized version.

28:21

They call it discontinuation syndrome.

28:24

Sounds like no big deal. But

28:27

in point of fact, there

28:29

are dozens, maybe scores, perhaps

28:32

hundreds of drugs, that if

28:34

you stop them suddenly, cold

28:36

turkey, so to speak, you

28:39

are going to go through hell. Oh,

28:43

yeah. So if

28:45

you look in the prescribing information for

28:47

the management

28:50

strategy, it's

28:52

not there. They say, oh,

28:54

gradual tapering. Well, what does

28:56

that mean? Exactly. Is

28:58

it days, weeks, months? There are some

29:00

drugs that it may take a year

29:03

or longer to get off. So

29:05

talk to us about

29:07

the discontinuation syndrome and how a

29:10

pharmacist could play a key role. Oh,

29:12

yeah. No, pharmacists are vital

29:14

for that process. And

29:17

there are specific drugs you cannot stop

29:19

cold turkey. It will lead to more

29:21

harm. Particularly, I'm

29:23

thinking about certain opioids, certain

29:26

benzodiazepines. Even

29:29

certain blood pressure medications, you just can't

29:31

stop because you may get some rebound

29:34

withdrawal effects. But this is

29:36

the beauty of a pharmacist. We kind of know

29:38

the basics of pharmacokinetics. We know how long a

29:40

drug may last in the body. We know how

29:43

it's cleared. We can do that based

29:45

on your weight, your age, your

29:47

kidney function. And so it

29:49

is not necessarily a fine art. You have to

29:52

play with how the patient responds. And so it

29:54

does take a little bit of variance

29:56

and wiggle room when it comes to that

29:58

table. What we've learned... is that

30:01

as you say, people are very different. And

30:04

so there's some people who can

30:06

stop an antidepressant like Lexapro,

30:08

let's just say, or Prozac for that

30:10

matter, in a couple of weeks and

30:13

do just fine. And there are other people

30:16

who have told us the

30:18

antidepressant Cymbalta deloxitine can

30:21

take months. In fact, there are some

30:23

people who remove one little bead from

30:25

the capsule, not

30:28

every day, but every week or

30:30

every month. And it can take some

30:33

cases over a year to get

30:35

off deloxitine without experiencing any withdrawal

30:37

symptoms. So

30:40

this is not a cookbook. It's

30:43

a very gradual process. Extremely.

30:46

Extremely gradual, especially when it comes

30:48

to these specific type of psych

30:51

medications that deal with the neurotransmitters in

30:54

our brain, we're playing

30:56

with the body's chemistry. And

30:58

so to your point, that class of

31:00

medication is extremely difficult. The

31:03

more notorious one is Effexor

31:05

or Venofaxine. People just have

31:08

the worst nightmares, like all types of

31:10

shakes. I mean, it's like you're going

31:12

through like a cocaine withdrawal. But

31:14

yeah, that is seen in that class of medications.

31:16

It's also seen in Benzes as well.

31:20

That Quinn, Effexor was actually a fairly

31:22

new drug. We took a call here

31:25

on the radio and

31:27

the individual was taking

31:29

Effexor and said, well, I

31:31

actually call it side Effexor. It's like American

31:33

Express. You don't want to leave home without

31:35

it. Because it's

31:37

a really short acting drug. And if

31:39

you miss a dose, you

31:42

are going to wish you

31:44

hadn't. Yeah,

31:47

it's, it's, yeah, yeah.

31:50

So it's useful in some situations, but

31:52

it's something that you really do have

31:54

to know about. Yeah.

31:56

And that's the problem. We are not

31:58

always transparent and telling people. hey, once

32:00

you start this, you may be on it

32:02

forever. And I'm not saying that

32:05

we should, but we're not giving people the

32:07

due justice of knowing what are the long-term

32:09

effects of trying to taper down later in

32:11

life. And so now you're 60,

32:14

you've been on this med forever and now it

32:16

could be causing issues later in life and we

32:18

don't know. And we

32:20

have heard that sort of

32:22

story from, for example, an

32:24

individual who was prescribed to

32:26

benzodiazepine because they were feeling

32:28

anxious and they had insomnia

32:31

after a loved one died. And now

32:33

it's 10 or 15 or

32:35

20 years later and they're still taking the

32:38

drug because how did they get off

32:40

it? And as we know,

32:42

benzodiazepines, I think most of them are

32:44

on that fierce list of drugs that

32:46

may be inappropriate for other people.

32:50

We heard from a family. A

32:54

woman said my

32:56

aunt was in a nursing home. She

32:59

was doing very badly. The doctor said

33:01

she was almost

33:03

ready to die. And

33:07

my sister and I, we were the family, she

33:10

didn't have kids. So we were

33:12

her family and we went to

33:14

the nursing home and we said, well, if she's almost

33:16

ready to die, can't we take her off some of

33:18

these drugs? And they said, she's

33:21

almost ready to die. Sure, we'll take her

33:23

off the drugs. What harm can

33:25

it do in the two or three

33:27

days she has left, right? So they took her

33:30

off the drugs. She

33:32

lived another two or three years with much

33:34

better quality of life. And

33:37

her mind came back. She recognized

33:39

them and she was, everyone was

33:41

like, whoa, what she

33:43

graduated. She graduated from hospice or

33:45

the nursing home in this meeting.

33:47

But this is not a rare

33:50

story. I hear it all the time. People are

33:52

on the way to hospice. They're thinking they're about

33:54

to die. They get off the meds and suddenly

33:56

they're back and it's like, let's do

33:58

that before it takes them going to the hospital. hospice.

34:00

Exactly because sometimes people wait too

34:03

long to go into hospice care

34:06

and it would be better

34:08

if they had that extra quality of

34:10

life earlier. Yeah and hospice isn't the end

34:12

of the road guys sometimes we forget that

34:15

we can use hospice for rehab and just

34:17

get back to where we need to be

34:19

so sometimes I recommend hospice for people in

34:21

those transitional states. Dr. Canterbury I'm going to

34:23

ask you a really tough question.

34:25

Good. So let's

34:27

just imagine you're a pharmacist and

34:31

maybe you're in a retail

34:33

pharmacy situation and

34:35

you get a notice on

34:38

your computer that says this patient

34:40

should not be receiving this new medicine

34:43

that the doctor has just prescribed

34:45

because it's contraindicated it's inappropriate it

34:47

could cause an interaction problem. Well

34:50

now you're caught in a

34:52

bind because the patient is waiting they've

34:55

just given you you know their prescription they want to get

34:58

it filled and they want to go home and you're

35:00

going I don't like

35:02

this you call the doctor

35:05

you get the receptionist the

35:08

receptionist says the doctors with

35:10

the patient can't talk now

35:12

you know now you're stuck

35:14

because the patient wants the

35:16

medicine doctor told the patient

35:19

he or she needed it but you can't

35:21

talk to the doctor it's contraindicated so you're

35:24

probably going to have to send the patient home without

35:26

the drug because it

35:28

could be very very dangerous but meanwhile you're

35:30

waiting for the doctor to call you back

35:33

and we have talked to many pharmacists who

35:35

say well sometimes sometimes I get a call

35:37

back the next day or

35:39

two days later and sometimes

35:43

I never get a

35:45

call. Yep.

35:48

Yeah you're painting my early

35:50

career in retail as

35:52

a pharmacy manager so it happens

35:54

pretty often depending on the response

35:56

time the clinic the office the

35:58

type of interaction that I'm looking

36:01

at. It's more of a process.

36:05

I'm looking at the same thing. I will call the doctor,

36:07

leave a message, and sometimes the doctor will just send a

36:09

new script without even talking to me. Sometimes

36:12

they'll want to talk and

36:14

actually get some more details as to why they're seeing

36:16

that interaction. Sometimes they just don't

36:18

know, and they're like, oh, okay, no clue.

36:20

Let's change it. And they appreciate us catching

36:22

it. So physicians really do appreciate the pharmacist's

36:24

role, but in that type of setting,

36:26

it could be quite fast-paced and stressful, and no one

36:29

wants to be in a pharmacy waiting for an

36:31

hour. So you've got to really just communicate

36:33

and level-set with the person in real time

36:35

and keep them abreast as things are updated.

36:37

So that's how I've been able

36:39

to build that rapport and trust with my patients.

36:41

And patients have to have trust in their pharmacist,

36:43

because if the pharmacist is catching a potential

36:47

interaction that could

36:50

maybe kill you, you better

36:54

pay attention, better

36:56

to go home, better to wait

36:58

for a follow-up, because sometimes

37:01

those drugs can interact

37:03

in a very bad way, and

37:06

the pharmacist is capable of catching that.

37:08

Yeah. And I

37:11

mean, a medical record can

37:13

only go so far, guys. You're

37:15

not going to always know the patient's allergies unless they

37:17

try it, they fail it, and now they're back in

37:19

the hospital. And then we've put

37:21

the allergy in. So some health systems aren't

37:23

always sharing that information. So to that point,

37:26

yeah, we've got to be thorough. You

37:29

are listening to Dr. Delon Canterbury.

37:32

He's founder of Geriatrics and

37:34

the De-Prescribing Accelerator. Dr.

37:37

Canterbury is a board-certified

37:39

geriatric pharmacist with a

37:41

passion for reducing harmful

37:43

medication use in older adults

37:46

across the country. After

37:48

the break, we'll discuss the

37:50

problem of alert fatigue. That's

37:52

when the computer says, oh,

37:55

be careful about this possible

37:57

interaction, or watch out, test

37:59

for... potassium levels. It's

38:01

a pretty serious problem. When

38:04

pharmacists intervene to prevent certain

38:06

interactions, they can save lives

38:08

without the patient even realizing

38:10

it. We often urge people to

38:13

talk with the pharmacist, but how

38:15

practical is that? Drive-thru windows at

38:17

the pharmacy promote the idea

38:19

that drugs are commodities and downplay

38:22

the potential importance of a

38:24

pharmacist's input. How does Dr.

38:26

Canterbury help patients interface with

38:28

doctors when it comes to

38:30

deep prescribing? You're

38:39

listening to The People's Pharmacy with Joe

38:41

and Terry Graydon. This

38:44

podcast is made possible in

38:46

part by Gaia Herbs. For

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39:23

back to The People's Pharmacy. I'm

39:25

Terry Graydon. And I'm Joe Graydon.

39:27

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in part by Coco-Via Dietary Supplements.

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with each serving containing 500 milligrams

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of cocoflavanols to support

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heart health. More information

39:45

at coco-via.com. If

39:47

you watch television at all, you

39:50

know that pharmaceutical manufacturers spend

39:52

a huge amount of money

39:54

on television commercials. There's

39:57

Rinvoke for ulcerative colitis,

39:59

rheumatoid arthritis, psoriatic

40:01

arthritis, and eczema.

40:04

Scirese ads promote its

40:06

use against plaxoriasis, psoriatic

40:08

arthritis, and Crohn's disease.

40:11

Mount Jarrow ads urge people with type

40:14

2 diabetes to do

40:17

diabetes differently. They

40:19

don't mention the other reason Mount Jarrow is

40:21

flying off the shelf, off-label use for

40:23

weight loss. Their heavily

40:26

advertised diabetes drugs include

40:28

Jardiance and Ozimpic. You

40:30

know, oh, oh,

40:32

oh, Ozimpic. Prescription

40:35

drug commercials feature people climbing

40:37

walls, flying planes, sailing boats,

40:39

riding motorcycles, dancing, or having

40:42

fun at the fair. They

40:44

really have helped normalize the idea

40:46

of taking a medicine, or more

40:48

than one, to stay healthy and

40:50

active. But the list of possible

40:53

drug side effects might give you pause.

40:55

It's not uncommon to learn

40:57

that a seemingly fantastic new

40:59

medicine can cause heart attacks,

41:01

strokes, kidney damage, cancer, or

41:04

death as an adverse drug

41:06

reaction. Your pharmacist can

41:08

help put the commercials into context. Has

41:11

your pharmacist saved your life? How

41:13

would you know? A lot goes

41:16

on behind the counter when it comes to

41:18

medication safety. If a new

41:20

prescription is incompatible with your

41:22

current regimen, the pharmacist may

41:24

step in to prevent catastrophe.

41:27

Or if that person is overworked

41:30

and overwhelmed, they might

41:32

experience alert fatigue and fail

41:34

to take the time to contact the

41:36

prescriber. Today's guest

41:38

is committed to helping patients

41:41

avoid dangerous drug interactions and

41:43

unnecessary prescriptions. Dr.

41:45

Delon Canterbury is the founder

41:47

of Geriatrics and

41:50

the deprescribing accelerator. Dr.

41:52

Canterbury is a board certified

41:55

geriatric pharmacist. Dr.

41:58

Canterbury, we were just talking

42:00

about the pharmacist

42:03

and the pharmacy, filling prescriptions.

42:06

As you say, fast-paced environment,

42:08

very stressful, and they

42:11

need to work fast. They

42:13

are filling a prescription and

42:15

a warning comes up on

42:17

the screen. This

42:21

prescription might have a problem. Do

42:25

you pay attention to that alert

42:28

or do you override it?

42:30

We have read some

42:32

research suggesting that prescribers

42:35

and pharmacists both

42:38

may sometimes override

42:41

alerts, computerized alerts. It's called

42:43

alert fatigue. Tell us

42:45

about it. I could

42:48

speak from first-hand experience

42:51

working in retail. You

42:54

get drug interaction alerts for

42:56

everything. You cannot

42:58

continue filling the script if you

43:00

don't override or at least find

43:03

a way to document while you're

43:05

overriding something. After

43:08

a while, when you're giving 100 COVID

43:10

shots, 50 flu shots, you're

43:12

behind on scripts, you have a tech call-out, you

43:14

didn't have a lunch break, very common. You

43:22

weigh what battle you want

43:25

to fight. You don't

43:27

always have the energy to fight every single

43:29

battle. I will say sometimes those alerts are

43:32

nonsense, bogus. There is a clinical

43:34

judgment that needs to be taken

43:36

into consideration. If you're telling me

43:38

a map result interacts with a

43:40

blood thinner, that's not a real

43:42

alert. It is an alert that

43:44

comes up chronically in our world.

43:47

Not when you needed to worry about.

43:49

Not when you have to worry about.

43:52

If it's like, oh, that's a major

43:54

interaction or contraindication or, oh, he's getting

43:56

an opioid filled at another pharmacy when

43:58

I checked his database. pill

46:01

and the antibiotic and the

46:03

blood pressure situation could lead

46:05

to something called hyperkalemia. Can

46:08

you explain what that is and

46:10

why it can be so dangerous? Yeah,

46:13

that's a great catch for that pharmacist.

46:15

Oh and by the way, what the

46:17

pharmacist did was tell the patient stop

46:19

taking your potassium pill while you're taking

46:21

this antibiotic. It could be deadly. Yeah,

46:24

yeah. Especially

46:26

this may have been an older

46:29

patient, but regardless, a combination of

46:31

three of those drugs can elevate

46:33

your serum potassium. Potassium

46:36

is important for our heart.

46:38

So we need potassium and sodium

46:40

for our blood to pump in

46:43

the body. If you have too

46:45

much potassium, it can

46:47

indeed stop that electrical signal in

46:49

the heart and it could lead

46:51

to failure. It could lead to

46:53

a fatal event or a cardiac

46:55

arrest. So that is a pretty darn

46:57

good catch, I will say. And hyperkalemia

47:00

can happen in many ways, but what

47:02

we're looking at here is the combination

47:04

of three or four drugs contributing to

47:06

it. Sulfur bactrim

47:08

alone has a risk of elevating

47:10

your serum potassium just for what

47:12

it is. If your kidney sucks,

47:15

it's going to even be more pronounced. Now

47:17

we're adding on potassium-sparing diuretic

47:19

and the blood pressure that can

47:21

elevate it. So all those drugs

47:23

combined can lead to that potentially

47:25

fatal life-threatening event. And

47:28

luckily this patient survived.

47:30

Yes. There

47:37

we go. Here's a question, Dr. Candlerberry.

47:40

We often advise people to talk to

47:42

the pharmacist about their drug questions. Is

47:45

that a practical recommendation? Do

47:48

pharmacists really have time to talk

47:51

to their customers about drug

47:53

questions? The

47:57

current climate of pharmacy will say otherwise.

48:00

I'm a huge fan of the mom and pops

48:02

that are out there the independent owned pharmacies they

48:05

tend to be I feel more Patient-centered

48:07

and centric you're gonna have darn good

48:09

pharmacists in any setting as much as

48:11

I you know the field tends to

48:14

look down upon the community setting but

48:17

Yeah, it's the most accessible

48:19

person your your 90%

48:22

of countries within five miles of a pharmacy

48:24

and so you can get pretty much free knowledge

48:27

free education I recommend going

48:29

when it's not as busy like nice like

48:31

be befriend them like get to know your

48:33

Pharmacists bring them some food, you know coffee

48:36

like I want to know when tell

48:38

me when when it's the best and

48:40

worst Time to get your prescription

48:42

filled honestly

48:46

the easiest time the

48:49

easiest time would be Overnight

48:52

if there is an overnight pharmacy

48:54

available usually like One

48:58

or two a.m. Would actually be the quickest and

49:00

easiest nobody's there. There's an overnight pharmacist It's probably

49:02

done in less than 10 minutes. I would say

49:04

if it's not that first thing in the

49:06

morning and Then maybe I'd

49:08

say an hour and a half two hours before

49:10

close if it's not like, you know Like eight

49:12

o'clock like if it's ten so I would say

49:15

that super super early or in the middle of

49:17

the night frankly so I

49:19

watch people go into pharmacies

49:21

a lot and There's

49:23

this grab and go mentality Yeah,

49:26

this grab and go mentality

49:29

seems to be prevalent Because

49:31

everybody's in a hurry these days the

49:34

pharmacist first of all is back behind

49:36

the counter I mean it you know

49:38

There's there's a wall between the pharmacist

49:40

and the front People and you can't

49:43

always tell if you're talking to a

49:45

pharmacist because the technicians are off Often

49:48

wearing some kind of a little white coat

49:50

or something with a label on it and you

49:52

just don't know Am I talking to the farms

49:54

and I talking to the technician who am I

49:56

talking to right? But people just grab their bag

49:58

and out they run And

50:01

it's like they're not taking

50:03

this opportunity to

50:05

discuss how to

50:08

take the medicine on an empty

50:10

stomach with food. What should you avoid? They're

50:12

not talking about what are the most common

50:14

side effects, what are the most dangerous

50:17

side effects, what symptoms do I look

50:19

out for? And actually

50:21

in North Carolina you have

50:23

to explicitly decline your opportunity

50:26

to talk to a pharmacist when

50:28

you pick up your medication. But

50:30

most people do, they decline. Why

50:32

is that such a bad idea? Why should

50:35

people take time? The pharmacist

50:37

is quote unquote free. You

50:40

get to have a conversation and learn

50:43

a lot about your medicines, but most

50:45

people don't take advantage of that service.

50:48

What you described was precisely

50:50

why I fell out of love

50:53

with pharmacy and got severely depressed

50:55

with my profession and healthcare as

50:58

a whole. And

51:00

it was the impetus for why I created

51:02

more of a personalized concierge

51:04

approach to medicine management and

51:07

pharmacists truthfully want to have those

51:09

conversations. We love getting those good

51:11

nice meaty questions about the meds

51:13

and how to take it, et

51:15

cetera. But the environment

51:18

constricts us from really doing it in a

51:20

way that I feel thorough and

51:23

to some people's needs if it's maybe an older

51:25

person, you got to spend a little more time,

51:27

a little more delicacy with managing that. The

51:30

American lifestyle is to have things fastened now.

51:33

Just like how we are prescribing habits is

51:35

to have something done, treated fast, and now

51:37

that's our lifestyle. We've been inculcated

51:40

with that type of mindset. So

51:42

when we're able to go back and reverse this

51:44

and just hold the horses, get to the root

51:46

cause of issues, we can

51:49

do a better service to people,

51:51

which is exactly why I feel

51:53

medicine is shifting the more concierge.

51:55

It's shifting the more direct primary

51:57

care. It's shifting the more just

51:59

the... medical care at home model. And

52:02

that's what I'm seeing in our generation of older

52:04

paudelts. We know a

52:06

pharmacist who calls it the

52:09

sort of McDonald's-ization of pharmacy.

52:12

There's now drive-through. It's

52:14

just like the pharmacist

52:16

is flipping burgers. Instead,

52:19

they're just flipping prescriptions.

52:22

And the idea is a lot of people think,

52:24

well, I'll just drive through and pick up my

52:26

prescription. It'll be fast. It'll be convenient. I

52:29

don't have to even go into the store. And

52:32

that mindset seems to me to

52:34

be counterproductive. Yeah,

52:36

I'm with you. I

52:38

was there with two drive-throughs trying to

52:40

manage the same and wondering why

52:43

we're prioritizing metrics

52:45

over patient care. Metrics,

52:49

meaning? Like how many prescriptions

52:51

are you filling? How fast are you

52:53

filling them? What's your phone hold time?

52:55

What's your flu shot counts? So

52:58

you're being monitored. We're monitored

53:01

and honestly incentivized. And monetized.

53:03

And monetized, yes. I

53:05

like that, sadly. But it's the

53:08

truth. So I found myself, like

53:10

you say, as a glorified bartender.

53:13

And I'm not going to deflect or

53:15

deflate on the profession. It's just what

53:17

I experienced in that setting made

53:19

me create a different way for people

53:22

with my company, Geriatrics. Well, tell

53:24

us, if you would, please, how your

53:27

company works. How would somebody get in

53:29

touch with you? Or are there other

53:31

companies similar to yours that somebody in

53:33

another place might be able to contact?

53:36

Yeah, absolutely. So there

53:38

aren't as many entrepreneurial pharmacists outside of

53:41

your pharmacy owners, but they are growing.

53:43

And I am a part of a

53:46

strong few that are doing this. And so

53:49

anyone can reach out to me, whether

53:51

it be through our website, geriatrics.org, or

53:54

reaching out on social media. We are on

53:56

all platforms, Facebook, Twitter, LinkedIn, you name it.

53:58

You can always send them out. message and

54:00

schedule directly with me to talk

54:05

about everything about the meds. When you see a situation where somebody is not

54:07

taking just 3, 4, 5 but maybe 10 or 15 patients

54:30

and you see, oh my goodness, there

54:32

are about 4 or 5 drugs here that

54:35

might be counterproductive, might be causing

54:37

some of the very problems that

54:39

we're trying to get rid of

54:41

with other drugs. How

54:44

do you help that patient interface with

54:46

their physician or how do you interface

54:49

with the physician? Because

54:51

sometimes doctors get a little defensive

54:53

about stopping a medication that they

54:55

prescribed maybe 3 or 4 years

54:58

ago. What

55:00

is the delicate dance that you have

55:03

to do to make that work? It's

55:05

definitely a dance. The first

55:08

step is education and empowerment. Our

55:11

patient needs to know, hey, did you realize

55:13

that this could be causing this and did

55:16

you ever communicate this concern?

55:19

Usually they don't. Usually they had no

55:21

clue. So now the second step is,

55:23

all right, let's build this case showing

55:25

why you may not need these medications.

55:27

That's where I come in with our

55:29

expertise. We provide a deprescribing action plan

55:31

for our families and patients. That's so

55:33

important. And the patient can then use

55:35

that, bring it to the office. But

55:37

we take it a step further and

55:39

actually do the advocacy and educating for

55:41

their providers on their behalf if they

55:43

choose one of our larger retainer model

55:46

packages. And so that's where we

55:48

do the calling, we do the faxing, we

55:50

do the interventional, I guess,

55:52

change for that patient and

55:55

show, again, the rationale, the clinical evidence,

55:57

using the Beers list, using the other

55:59

tools. You

58:00

can find it online at peoplespharmacy.com.

58:02

That's where you can share your

58:04

comments about today's interview and find

58:07

a link to Dr. Canterbury's website.

58:09

You can also reach us through email, radio

58:12

at peoplespharmacy.com. Our interviews are

58:14

available through your favorite podcast

58:16

provider. You'll find the show

58:18

on our website on Monday

58:20

morning. At peoplespharmacy.com, you could

58:22

sign up for our free

58:24

online newsletter. In

58:26

Durham, North Carolina, I'm Joe Graden.

58:28

And I'm Terri Graden. Thank you

58:30

for listening. Please join us again next. Thank

58:45

you for listening to the People's Pharmacy

58:47

Podcast. It's an honor and a pleasure

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